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A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an AP?
- A. Feeding client admitted 24h ago with aspiration pneumonia
- B. Reinforcing teaching with client learning to walk using a quad cane
- C. Reapplying a condom catheter for a client with urinary incontinence
- D. Applying sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C: Reapplying a condom catheter for a client with urinary incontinence. This task involves non-invasive, routine care that can be safely delegated to an assistive personnel (AP). The nurse should ensure that the AP is trained and competent in performing this procedure.
Choice A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse due to the risk of complications.
Choice B: Reinforcing teaching with a client using a quad cane involves critical thinking, assessment of the client's understanding, and ensuring safety, which should be done by a licensed nurse.
Choice D: Applying a sterile dressing to a pressure ulcer requires sterile technique, assessment of wound status, and potential need for wound care interventions, which should be performed by a licensed nurse.
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An RN is making assignments for client care to an LPN at the beginning of shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24h post-op to use incentive spirometer
- B. Collecting clean-catch urine specimen
- C. Providing nasopharyngeal suctioning for pneumonia client
- D. Replacing cartridge & tubing on PCA pump
Correct Answer: D
Rationale: The LPN should question replacing cartridge & tubing on PCA pump (Choice D) because this task involves manipulating the patient's medication delivery system, which is beyond the LPN's scope of practice. LPNs are not trained to handle complex medication administration devices like PCA pumps, as this requires a higher level of knowledge and skill typically reserved for RNs. The LPN should advocate for clarification from the RN or delegate this task to someone with the appropriate training. Choices A, B, and C are within the LPN's scope of practice and do not require specialized training like manipulating a PCA pump.
Nurse wearing sterile gloves in prep for performing sterile procedure. Which of following objects may nurse touch without breaching sterile technique?
- A. Bottle containing sterile solution
- B. Edge of sterile drape at base of field
- C. Inner wrapping of an item on sterile field
- D. Irrigation syringe on sterile field
- E. 1 gloved hand with the other gloved hand
Correct Answer: C,D,E
Rationale: The correct choices are C, D, and E. The nurse can touch the inner wrapping of an item on the sterile field because it is considered sterile. The nurse can touch the irrigation syringe on the sterile field as long as it is also considered sterile and part of the field. The nurse can also touch one gloved hand with the other gloved hand, as the gloves are considered sterile. Choices A and B are incorrect because touching the bottle or the edge of the drape would breach sterile technique.
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
- A. Thermometer
- B. Elastic stockings
- C. Blood pressure cuff
- D. Sequential compression devices
Correct Answer: C
Rationale: The correct answer is C: Blood pressure cuff. To assess for orthostatic hypotension, the nurse needs to measure the patient's blood pressure in different positions - lying down, sitting, and standing. This is done using a blood pressure cuff to monitor any significant drop in blood pressure upon changing positions. A thermometer (choice A) is used to measure temperature and is not relevant to assessing orthostatic hypotension. Elastic stockings (choice B) are used for compression therapy in conditions like venous insufficiency and do not help in assessing orthostatic hypotension. Sequential compression devices (choice D) are used for preventing deep vein thrombosis and improving circulation, not for assessing orthostatic hypotension.
A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?
- A. Increased appetite
- B. Increased diarrhea
- C. Increased metabolic rate
- D. Altered nutrient metabolism
Correct Answer: D
Rationale: The correct answer is D: Altered nutrient metabolism. Immobility can lead to changes in nutrient metabolism due to decreased physical activity and muscle mass. The body may start breaking down muscle tissue for energy, leading to altered nutrient metabolism.
A: Increased appetite is not directly related to immobility and is unlikely to be a metabolic alteration seen in this patient.
B: Increased diarrhea is more likely related to gastrointestinal issues rather than a direct metabolic alteration due to immobility.
C: Increased metabolic rate is unlikely in an immobile patient as physical activity is decreased.
Therefore, D is the correct choice as it directly relates to the metabolic changes associated with immobility.
A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?
- A. Moves patient's arm in a full circle
- B. Moves patient's arm across the body as far as possible
- C. Moves patient's arm behind body, keeping elbow straight
- D. Moves patient's arm until thumb is upward and lateral to head with elbow flexed
Correct Answer: D
Rationale: The correct answer is D. To perform external rotation of the shoulder, the nurse should move the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position optimally engages the external rotators of the shoulder joint, allowing for the desired movement. Choice A involves a full circle motion, which does not specifically target external rotation. Choice B focuses on adduction rather than external rotation. Choice C involves extension of the shoulder rather than external rotation. Therefore, the correct answer is D as it aligns with the anatomical movements required for external rotation of the shoulder joint.